Original Article J Babol Univ Med Sci

22; 2020. P: 215-221

Effect of Using Bulk fill Composites on Fracture Resistance of

Maxillary Premolars with MOD Cavities

N. Shadman (MSc)1, R. Hoseinifar (MSc)2, M. Ghafar Poor (DDS)3 , D. Dortaj (DDS)2

1.Oral and Dental Diseases Research Center, Kerman University of Medical Sciences, Kerman, I.R.Iran
2.Department of Operative Dentistry, School of Dentistry, Kerman University of Medical Sciences, Kerman, I.R.Iran
3.Dentist, Zahedan, I.R.Iran

J Babol Univ Med Sci; 22; 2020; PP: 215-221

Received: Oct 31st 2019, Revised: Jan 5th 2020, Accepted: Jan 25th 2020.
ABSTRACT
BACKGROUND AND OBJECTIVE: Bulk fill composites are an innovative class of dental resin composite materials,
developed to simplify the restoration procedures, and are preferred to conventional composites if they have good
mechanical properties and marginal seal. The aim of this study was to evaluate the fracture resistance of premolar teeth
with mesio-occlusodistal (MOD) cavities restored with bulk and conventional composites.
METHODS: In this experimental in-vitro study, 40 sound maxillary premolar teeth were randomly divided into five
groups: Group I: Positive control, intact teeth. In the remaining four groups, MOD cavities were prepared. Group II:
Negative control, unrestored teeth. In other groups, cavities were restored as follows; Group III: (X-tra fil, bulk filling
with 4mm-thick increment), Group IV: (X-tra base, bulk filling+Grandio, incremental filling) Group V: (Grandio,
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incremental filling with 2mm-thick increment). The restored teeth were stored in distilled water for 24 hours at 37oC and
thermocycled (500 cycles). Specimens were subjected to a compressive load until fracture, and the fracture resistance
was recorded in Newton.
FINDINGS: The highest fracture resistance values were obtained in group I (1150±507 N) and the lowest in group II
(85±62.51 N), which was significantly lower than other groups (p=0.001). The fracture resistance of bulk fill composites
and conventional composite did not differ significantly with intact teeth.
CONCLUSION: The restoration of teeth with moderate MOD cavity size using bulk fill composites can restore the lost
tooth strength to a level comparable to intact teeth and similar to conventional composite.
KEY WORDS: Composite Resins, Tooth Fracture, Polymerization.

Please cite this article as follows:

Shadman N, Hoseinifar R, Ghafar Poor M, Dortaj D. Effect of Using Bulk fill Composites on Fracture Resistance of Maxillary
Premolars with MOD Cavities. J Babol Univ Med Sci. 2020; 22: 215-21.
[ DOI: 10.22088/jbums.22.1.215 ]

*Corresponding Author: R. Hoseinifar (MSc)

Address: Department of Operative Dentistry, School of Dentistry, Shafa Street, Kerman, I.R.Iran
Tel: +98 34 32119022
E-mail: : R_hoseiniffar@yahoo.com
 216
Introduction
Removal of dental structures during cavity
preparation, can weaken teeth, predisposing complete or
incomplete fracture (1). Stress transfer occures
differently in intact versus restored teeth (2(. Various
studies have been conducted on the dental structure
strength after Mesio Occluso Distal (MOD) cavity
preparation and the effect of different restorative
materials on the strength of the remaining structures. It
has been confirmed that the cuspal flexure can be
reduced with bonding restorations compared with
amalgam restorations (1), and these restorations are
able to partially or completely improve poor fracture
resistance (3). The fracture resistance of restored teeth
is influenced by several factors, including the type of
tooth, size and extent of cavity, type of restorative
material used, presence or absence of marginal ridge
and the amount of shrinkage and bond strength of
composite (2, 4).
The polymerization shrinkage of composites is
a common concern (5). Polymerization stress
distribution is affected by factors such as type of
composite, cavity dimensions, filling technique and
light cure process (6) and provide better tooth protection
against fatigue caused by occlusal forces and thermal
changes (7).
Moreover, various techniques have been introduced
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to reduce shrinkage, including incremental techniques,
use of stress-breaker liner, change in the photo-initiator
system and the use of low-shrinkage composites. The
incremental composite placement is a standard
technique in cavities with more than 2 mm depth, but it
is time-consuming and increases the risk of voids and
poor adaptation between layers, so it is very useful to
provide new methods to take less time with better
physical properties such as the use of bulk fill
composite, which has recently been introduced to the
market, and has the ability to place the restoration to a
thickness of 4 mm (8, 9). Slow polymerization, efficient
cure and less shrinkage in bulk fill composites lead to
reduced cuspal flexure (10, 11(.
Differences exist in the light activation system, filler
[ DOI: 10.22088/jbums.22.1.215 ]
size and loading and translucency in the bulk fill
composites, which reduces shrinkage stress and
increases the depth of cure (12(. Moorthy et al. (2012)
indicated that bulk fill flowable composite significantly
reduced the cuspal deflection compared to conventional
composites, though had no effect on the degree of
microleakage (13). Taha et al. in 2017 evaluated the
effect of bulk fill composites on the fracture strength
Fracture Resistance of Maxillary Premolars; N. Shadman, et al
and pattern in root-canal-treated teeth and MOD
cavities using different types of composites. The results
showed that the fracture strength in bulk fill composites
had no significant difference with intact teeth (14).
Mincik et al. in 2016 compared the effect of different
restorative materials on the fracture resistance of the
endodontically treated maxillary premolars, and
observed no difference between the bulk fill and
conventional composites (15). Moreover, similar
result was obtained by Assis (16). In a study by
Atalay et al. in 2016, it was concluded that the
fracture resistance of teeth restored with bulk fill
composites were significantly lower than intact teeth
(17). The aim of this study was to evaluate the effect of
bulk fill and conventional composites on the fracture
resistance of the maxillary premolars with MOD
cavities.
Methods
This in vitro experimental study, which was
approved by the ethics committee of Kerman University
of Medical Sciences under ethical code
IRKMU.REC.1395.957, was conducted on 40 sound
maxillary premolars, without any caries and crack.
After removing calculus and soft tissue, they were
disinfected and restored in saline solution. The teeth
selection was based on having similar mesiodistal and
buccolingual dimensions. The selected teeth were
randomly divided into five groups. The specification of
the materials used in this study is presented in table 1.
The groups were as follows;
Group 1 (Positive control; intact teeth, without
preparation): In the other four groups, the MOD
cavities were prepared using a cylindrical diamond bur
01 (Teezkavan, Iran) with air-water coolant as follows:
Occlusal width: 1/2 distance between two cusps, pulpal
depth: 2 mm, proximal box width: 1/2 of faciolingual
tooth dimension, axial wall depth: 1.5 mm,
occlusogingival box height: 4 mm and gingival margins
were placed above the cementoenamel junction (CEJ).
Each bur was replaced after 5 preparations.
Group 2 (Negative control; those prepared as
described above and without any restoration): In
Groups 3, 4 and 5 the cavities were fulfilled as follows:
First, the metal matrix strip was fixed using a tofflemire
holder. Then, all walls of the cavities were etched with
35% phosphoric acid (Vococid, Voco, Germany),
washed and dried with cotton pellets, two coats of
Solobond M adhesive (Voco, Germany) were applied
 J Babol Univ Med Sci; 22; 2020 217

30 seconds on all walls, and were dried with gentle air
and then light-cured using Quartz Tungsten Halogen
(QTH) light curing device (Coltolux 75, USA) with a
minimum intensity of 600 mW/cm2 from the closest
possible distance, which was monitored with a
radiometer. The adhesive was cured for 20 seconds in
each area by overlapping. Then, the restoration
procedure was completed as mentioned below.
Group 3 (X-tra fil composite): each box was first filled
individually with the composite so that the thickness of
the first layer was 4 mm. After 40 seconds light curing
of each box, the occlusal part was cured and filled also
in a single step. After removing the matrix band, each
buccal and lingual box was cured for 20 seconds.
Group 4 (X-tra base+Grandio): each of the boxes
were first filled separately with a thickness of 4 mm X-
tra base, and cured. The occlusal part was also filled and
cured with incremental method by the Grandio
composite.
Group 5 (Grandio composite): the teeth were restored
by the incremental method (each layer with a maximum
thickness of 2 mm) and cured the same as other groups.
All restorations were restored in water for 24 hours
at 37°C and then thermocycled for 500 times (5-55°C)
(Baradaran Pouya, Iran). In the next step, the specimens
were mounted in self-curing acrylic resin (Acropars,
Iran) to 1 mm below the CEJ and then samples were
placed in universal testing machine (Testometric M350-
10CT, England) to test the fracture resistance under the
compression force along the longitudinal axis of the
tooth. The cross-head speed of the device was
1mm/min. The fracture resistance was recorded in
Newton. The fracture modes of the specimens were
determined using a stereomicroscope and according to
the following specification, determined by Burk et al.
(1):
Mode 1: Minimal destruction of teeth
Mode 2: Fracture of one cusp, without restoration
fracture
Mode 3: Fracture of at least one cusp and up to one-half
of the restoration
Mode 4: Fracture of at least one cusp and more than
one-half of the restoration
Mode 5: Severe fracture in most of the tooth structure
and/or vertical fracture.
Data were analyzed by SPSS version 20 using
ANOVA and Tukey's post hoc test. p<0.05 was
considered as the level of significance.

Table 1. The specification of the materials used in this study

Type Material Organic or inorganic matrix Manufacturer Filler percentage
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Matrix methacrylate
Bulkfill composite 86% wt.
X-tra fil Bis-GMA,UDMA,TEG-DMA Voco, Germany
with high viscosity 70.1% vol.

Matrix methacrylate
Bulkfill composite
X-tra base Bis-GMA,UDMA,TEG-DMA Voco, Germany 75% wt.
with low viscosity

Matrix methacrylate
Conventional 87% wt.
Grandio Bis-GMA,TEG-DMA Voco, Germany
Composite 71.4 vol.

Results
The highest and lowest values of fracture resistance
were obtained in the positive (1150±570) and negative
control group (85±62.51), respectively. The mean
[ DOI: 10.22088/jbums.22.1.215 ]
fracture resistance of restored teeth with bulk fill
composites (X-tra fill and X-tra base) and conventional
composite did not differ significantly with intact teeth

fracture resistance values (in Newton) of the studied
samples are shown in Table 2.
Tukey's analysis showed that only the negative
control group (group 2) had significantly less
fracture resistance than the other groups (p=0.001) and
the difference among the other groups was not
significant (p>0.05). This means that the
(p=0.89, 0.112, 0.92 respectively). The fracture patterns
of restored teeth are shown in Table 3.
The sound teeth showed seven fractures of one cusp,
among which six cases were in the lingual cusps. The
prepared unrestored teeth revealed 4 cases of fracture in
the lingual cusp and 3 cases with mode 5 and one case
of fracture in two cusps.
 218 Fracture Resistance of Maxillary Premolars; N. Shadman, et al

Table 2. The mean fracture resistance values±standard deviation (in Newton) of the studied samples
and two-by-two comparison of groups
Groups Mean±SD P-value
1 (intact teeth)a
Prepared unrestored teeth 0.001
Restored teeth with X-tra fil 1150±507 0.89
Restored teeth with X-tra base 0.112
Restored teeth with Grandio 0.92
b
2 (prepared unrestored teeth)
Restored teeth with X-tra fil
85±62.51 0.001
Restored teeth with X-tra base
Restored teeth with Grandio
3 (Restored teeth with X-tra fil)a
Restored teeth with X-tra base 1012±236.38 0.49
Restored teeth with Grandio 1.00
4 (Restored teeth with X-tra base)a
761.87±248.45 0.44
Restored teeth with Grandio
5 (Restored teeth with Grandio)a 1026±316.39

Table 3. The fracture patterns of specimens in the studied groups

Group Mode 1 Mode 2 Mode 3 Mode 4 Mode 5
X-tra fil 0 3 3 3 1
X-tra base 1 1 1 5 2
Grandio 4 1 0 3 2
Mode 1: Minimal destruction of teeth, Mode 2: Fracture of one cusp, without restoration fracture, Mode 3: Fracture of at least
one cusp and up to one-half of the restoration, Mode 4: Fracture of at least one cusp and more than one-half of the restoration,
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Mode 5: Severe fracture in most of the tooth structure and/or vertical fracture

Discussion
According to the results of this study, the sound
teeth exhibited the highest mean fracture resistance,
which is in agreement with the results of a large number
of studies (17, 18). Higher fracture resistance of sound
teeth is due to the rigidity and existence of intact buccal
and palatal cusps and mesial and distal marginal ridges,
which maintains the integrity of the tooth (19).In this
study, the lowest amount of fracture resistance was
found in the group II, which was significantly lower
than the other groups. This can be attributed to the
amount of remaining tooth structure after the MOD
cavity preparation and the weakening of tooth structure,
due to the loss of marginal ridges (19). The loss of
[ DOI: 10.22088/jbums.22.1.215 ]
22). This may be due to the micromechanical adhesion
between the tooth structure and adhesive, which tends
to splint the walls of prepared tooth together and
strengthen the residual tooth structure (19). Atalay et al.
(17) evaluated the fracture resistance of root canal-
treated teeth restored with various composites and
showed that the fracture resistance of intact teeth was
significantly higher than the other groups, which is
inconsistent with the results of our study, probably due
to the form of cavity preparation (an access+MOD
cavities). The access cavity preparation can cause more
stress accumulation in tooth compared with vital tooth,
which may be due to increased volume of composite

marginal ridge integrity is the main factor in the loss of
tooth resistance. The MOD cavity preparation on
average decreases 63% of tooth rigidity (20). According
to the results of this study, all restored teeth, regardless
of the type of material, showed the fracture resistance
comparable to intact teeth. Studies have shown that the
use of composite with adhesive, directly or indirectly,
increases the fracture resistance of restored teeth (21,
consumption. In addition, the level and the severity of
cuspal flexure are greater in endodontically treated teeth
due to the dentin removal in the cervical area (20). Taha
et al. (23) showed that the elastic modulus and
polymerization shrinkage of composites are the main
factors influencing the fracture resistance of composite
restorations. The restorations with high-modulus
composites show less cusp movement and protect the
 J Babol Univ Med Sci; 22; 2020
teeth from the fatigue caused by occlusal forces or
thermal changes (23). Grandio has been introduced in
various studies as the best material for flexural strength
and elastic modulus (24, 25). Ilie et al. showed that X-
tra fil, among the bulk fill composites, has the highest
elastic modulus (26). Papadogiannis et al. (2015) also
revealed that X-tra base among the bulk fill flowable
composites has the highest filler percentage (74% vol),
resulting in less deformity under occlusal loadings (27).
The polymerization shrinkage is also an effective
component of fracture resistance restorations (27).
Grandio is a composite with a high filler content, which
results in the reduction of polymerization shrinkage
(1.57%) (28). In bulk fill composites, due to changes in
monomer formulations, the use of stress-reducing resins
and slower reaction of polymerization during light
curing, the shrinkage stress during polymerization was
reduced (29, 30).
The results of this study showed that the fracture
resistance of restored teeth with the bulk fill composites
(both flowable and paste consistencies) was not
significantly different from conventional composite.
Isufi et al. (20) showed no significant difference in the
fracture resistance of restored teeth with the bulk fill
flowable composite (SDR) compared with conventional
composite. Rabuer et al. (2016) also indicated that the
teeth restored with conventional composite (Tetric N-
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Ceram) and high-consistency bulk fill composite (Tetric
N-Ceram Bulk) present similar fracture resistance (31),
which is in agreement with this study. The present study
[ DOI: 10.22088/jbums.22.1.215 ]
219
showed that there was no significant difference in the
fracture resistance between the two different
consistencies of the bulk fill composites. Although
flowable composites exhibit higher polymerization
shrinkage than paste type composites, their shrinkage
stress is low due to their lower elastic modulus and the
possibility of more flow before the Gel-point stage.
Furthermore, although the polymerization shrinkage of
the bulk fill flowable composite used in this study was
2.7%, the final layers of restorations were coated with
the composite with low polymerization shrinkage (10,
25). The maxillary premolars due to anatomical shape
and cusp inclination are more likely to fracture under
the occlusal loading than other posterior teeth (32, 33).
The cohesive fracture analysis of tooth structure has
shown that the probability of palatal cusp fracture of
maxillary premolars is more than buccal cusps (23),
which is similar to this study. In our study, the intact
teeth exhibited six lingual cusps fracture compared with
one buccal cusp fracture. The present study showed that
the restoration of teeth with moderate MOD cavity size
using both consistencies of bulk fill composites can
restore the lost tooth strength to a level comparable to
intact teeth.
Acknowledgment
The authors would like to thank the Kerman
University of Medical Sciences for financial support of
the research.
 220 Fracture Resistance of Maxillary Premolars; N. Shadman, et al

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[ DOI: 10.22088/jbums.22.1.215 ]

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